Health inspection·April 26, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident had a diagnosis of epilepsy and was at risk for side effects and ineffectiveness of medications with interventions that included to give seizure medications as ordered by doctor. Monitor/document side effects and effectiveness. Further review of the comprehensive care plan, under the same epilepsy focus category revealed Resident #45 received Benztropine Mesylate per the physician's orders. Resident #45's comprehensive care plan revealed the resident received antipsychotic medications related to bipolar disorder with interventions that included to administer medications as ordered, monitor/document for side effects and effectiveness and the resident received Depakote Sprinkles as per the physician orders. During an interview on 4/25/23 at 4:41 p.m., Resident #45 revealed she did not have a seizure disorder. Resident #45 stated, I have dementia and I'm bipolar. During an interview on 4/25/23 at 5:21 p.m., the DON revealed Resident #45 had been diagnosed with bipolar disorder and a seizure disorder. The DON revealed Resident #45 had not had any seizures since the DON had been employed at the facility since 10/24/22. The DON, after reviewing Resident #45's Order Summary Report revealed Resident #45 did not have an active order for medications to treat seizures. The DON stated, the MDS Coordinator oversaw revising and updating the comprehensive care plans. During an interview on 4/25/23 at 5:44 p.m. the LVN MDS Coordinator revealed, the comprehensive care plan was generated by an RN and the LVN MDS Coordinator, under the direction of the RN, revised the care plan, as necessary. The LVN MDS Coordinator stated, I know Resident #45 has a seizure disorder diagnosis. We (MDS Coordinator) rely on the orders and the nurse practitioner's notes to help develop and revise the comprehensive care plan, as necessary. The LVN MDS Coordinator revealed, the purpose of the care plan was to set goals and had to be measurable and used as a guide to know how to provide care to the resident. The LVN MDS Coordinator stated, regardless of the use, Resident #45 was on Depakote, so was still on a seizure medication even though it was prescribed for mood. We are just not being specific to the medication, and I believe there is a fine line. I think the care plan is accurate. During a follow up interview on 4/25/23 at 6:38 p.m., the DON revealed, the purpose of the comprehensive care plan was to provide information on the care and treatment for the residents. The DON stated, even though the Depakote (for resident #45) was care planned for bipolar disorder, the Depakote could be prescribed for seizure disorder and the care plan is accurate. The DON further revealed, Resident #45 was treated with Benztropine Mesylate and was indicated on the care plan as an intervention for the treatment of seizures. The DON then revealed, Resident #45's care plan was inaccurate because Benztropine Mesylate was a medication that would not be prescribed for seizures. The DON revealed she did not believe the inaccuracy of the care plan would cause Resident #45 to have a negative outcome. Record review of the facility policy and procedure titled, Comprehensive Person-Centered Care Planning, undated, revealed in part, .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .5. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment and as needed. Interventions put in place are to (be) followed as the plan of care for the resident. These interventions may be adjusted or resolved as needed to facilitate resident needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676325 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Nursing and Rehabilitation Center 8707 Lakeside Parkway San Antonio, TX 78245 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility failed to remove expired thickening liquid found within 1 of 1 kitchen dry food storage and 1 of 1 nutrition room. This failure could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation on 4/25/23 beginning at 11:53 AM revealed 6 quarts of liquid thickener all dated EXP 3/5/23 within the dry food storage in the kitchen. Interview on 4/25/2022 at 2:31 PM, the DM stated he did not recall the liquid thickener and only saw the unexpired liquid thickener in the dry food storage. The DM stated anyone who entered the dry food storage was meant to remove any expired food, but he completed an unrecorded audit daily of the food in addition to when food delivery are made. The DM stated the risks associated with having food in the dry food storage was it may be served to residents and cause foodborne illness. The DM stated the facility nutrition room was stocked by the dietary department but was fully maintained by the nursing department. Observation on 4/25/23 at 5:36 PM, 2 units of liquid thickener dated 2/14/23 and 3/5/23 within the reach-in refrigerator in nutrition room. Interview on 4/25/23 at 5:46 PM, the DON stated the facility had 1 total nutrition room and it was maintained by the nursing department with the food supplies provided by the dietary department. The DON stated the dietary department affirmed the quality of the food when it was provided but the nursing department was intended to evaluate all items when providing it to residents. She stated the ADON's have the sole responsibility of auditing the nutrition room fridge. She stated when she evaluated the nutrition room yesterday, the thickening liquid was not there. She stated the risk associated with having expired food in the nutrition room refrigerator was that it may be served to residents and cause foodborne illness. Interview on 4/25/23 at 5:57 PM, the Infection Preventionist/ADON stated he was the sole ADON responsible for auditing the nutrition room and completed a daily audit. He stated this morning, the expired thickening liquid was not in the reach-in refrigerator. He stated the risk with having expired food in the nutrition room refrigerator had the potential of serving the food to residents and causing foodborne illness. Record review of the facility nutritional policy titled Food Storage, dated 8/2007, revealed It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. Record review of US Food Code, dated 2017, revealed (F) MEAT and POULTRY that is not a READY-TO-EAT FOOD and is in a PACKAGED form when it is offered for sale or otherwise offered for consumption, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676325 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Nursing and Rehabilitation Center 8707 Lakeside Parkway San Antonio, TX 78245 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete shall be labeled to include safe handling instructions as specified in LAW, including 9 CFR 317.2(l) and 9 CFR 381.125(b). Record review of US Food Code, dated 2017, revealed The shelf life of ROP foods is based on storage temperature for a certain time and other intrinsic factors of the food (pH, aw, cured with salt and nitrite, high levels of competing organisms, organic acids, natural antibiotics or bacteriocins, salt, preservatives, etc.). Each package of food in ROP must bear a use-by date. In some cases such as cook chill or sous vide processing when none of these intrinsic factors are present, a temperature lower than 3ºC (38ºF) must be the controlling factor for C. botulinum and L. monocytogenes growth and/or toxin formation. This use by date cannot exceed the number of days specified in one of the ROP methods in Section 3-502.12 or must be based on laboratory inoculation studies. The date assigned by a retail repacker cannot extend beyond the manufacturer's recommended expiration or pull date for the food. The use-by date must be listed on the principal display panel in bold type on a contrasting background for any product sold to consumers. Any label on packages intended for consumer sale must contain a combination of a sell-by date and use-by instructions which makes it clear that the product must be consumed within the number of days determined to be safe as specified under Section 3-502.12 of the Food Code. Foods, especially fish, that are frozen before or immediately after packaging and remain frozen until use should bear a label statement, Important, keep frozen until used, thaw under refrigeration immediately before use. Raw meat and poultry packaged using ROP methods must be labeled with safe handling instructions found in 9 CFR 317.2(l) and 9 CFR 381.125(b) Event ID: Facility ID: 676325 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Nursing and Rehabilitation Center 8707 Lakeside Parkway San Antonio, TX 78245 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the binding arbitration agreement provided for the selection of a venue that is convenient to both parties for three of three residents (Residents #45, #53, and #57) reviewed for facility compliance with requirements for binding arbitration agreements. Residents Affected - Many The facility failed to ensure that its arbitration agreement provided for the selection of a venue that is convenient for both parties for Residents #45, #53, #57. These failures put residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services to be performed by the nursing facility. The findings included: Record review of Resident #45's face sheet, dated 4/25/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epileptic seizures (disorder of the brain characterized by repeated seizures; a temporary change in the electrical functioning of the brain), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and lack of coordination. Record review of Resident #45's Arbitration Agreement dated 2/28/22 did not provide for the selection of a venue that was convenient for both parties and stated arbitration will take place in the county that the facility is located in without any additional corollary or area of venue or setting changes. Record review of Resident #53's Face Sheet dated 4/25/23 reflected a [AGE] year-old male with an admission date of 5/13/22 and a primary diagnosis of dementia (A decrease in cognitive abilities or mental decline.) Record review of Resident #53's Arbitration Agreement dated 5/13/22 did not provide for the selection of a venue that was convenient for both parties and stated arbitration will take place in the county that the facility is located in without any additional corollary or area of venue or setting changes. Record review of Resident #57's Face Sheet dated 4/25/23 reflected a [AGE] year-old male with an admission date of 12/10/19 and a primary diagnosis of hemiplegia and hemiparesis follow cerebral infarction (partial paralysis after a heart attack.) Record review of Resident #57's Arbitration Agreement dated 12/10/19 did not provide for the selection of venue that was convenient for both parties and stated arbitration will take place in the county that the facility is located in without any additional corollary or area of venue or setting changes. Interview on 4/25/23 at 6:09 PM, the Business Office Manager stated she assisted with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676325 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Nursing and Rehabilitation Center 8707 Lakeside Parkway San Antonio, TX 78245 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0848 Level of Harm - Potential for minimal harm Residents Affected - Many arbitration agreements but the primary contact for residents and prospects would be the Admissions Coordinator or the Operations Manager. She stated when potential residents have additional questions during the admissions process, those are posed to the Operations Manager. Interview on 4/25/23 at 6:25 PM, the Admissions Coordinator stated she had only recently been in the role as an admissions coordinator and was not very familiar with the arbitration component of the admissions packet. The Admissions Coordinator stated during admissions she provided the packet to the potential resident or the family but will read parts of the packet to them. She stated when potential residents have additional questions, she directed them to the Operations Manager. She stated in reviewing the arbitration agreement, she only identified within the agreement describing the venue for a potential arbitration would be the sentence describing [it] will take place in the county that the facility was located in. Interview on 4/25/23 at 6:36 PM, the Operations Manager stated the Arbitration Agreement contained in the admission packet provided to the survey team on 4/23/23 was the Arbitration Agreement currently used by the facility, and that to his knowledge it was the document that had been in use since the facility changed ownership in October of 2022. The Operations Manager stated he received the arbitration agreement from corporate to provide during admissions and potential changes would need to be submitted to his corporate structure and reviewed by legal. The Operations Manager stated the only area within the arbitration agreement that references the venue was the sentence describing that it would take place in the county of the facility. The Operations Manager stated additional questions about arbitration during admissions are posed to him and he assures potential residents that assistance was provided to residents in travel accommodations such as during potential arbitration, however that this was not stated within the arbitration agreement. The Operations Manager stated the facility did not have a policy for arbitration agreements or admissions as the admissions packet was their policy. Record review of the admission packet reflected the arbitration agreement that stated arbitration will take place in the county that the facility is located in. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676325 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Nursing and Rehabilitation Center 8707 Lakeside Parkway San Antonio, TX 78245 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection to include sanitizing of medical equipment for 3 of 3 Residents (#64, #57, and #60) reviewed in that: Residents Affected - Few 1. The MA did not sanitize the blood pressure cuff before or after use with Resident #64. 2. The MA did not sanitize the blood pressure cuff before or after use with Resident #57. 3. The MA did not sanitize the blood pressure cuff before or after use with Resident #60. The failure could affect residents who had their blood pressure taken in the facility and placed the residents at risk for cross-contamination and the spread of infection. Findings included: Record Review of Resident #64 face sheet dated 04/26/2023, revealed the Resident was admitted to the facility on [DATE] with diagnoses that included essential primary hypertension (high blood pressure), glaucoma (causes problems with vision), neuropathy ( nerve damage), muscle wasting, major depressive disorder (causes feelings of lessened self- worth as well as feelings of sadness and loneliness), and age related cognitive decline (causes difficulty in through processing and ability to process information taken in by the brain). Record Review of Resident #57 face sheet dated 04/26/2023, revealed the Resident was admitted to the facility on [DATE] with diagnoses that included contracture of muscle multiple sites, cognitive communication deficit, muscle weakness, muscle wasting, acute respiratory failure, kidney failure, aphasia ( language disorder that affects a person's ability to communicate), epilepsy (seizure disorder), essential hypertension (high blood pressure), pruritus (itching), disorder of the skin and subcutaneous tissue, unspecified. Record Review of Resident #60 face sheet dated 04/26/2023, revealed the Resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following a stroke (weakness and paralysis) of left non-dominate side, difficulty walking, dysphagia (difficulty swallowing), reduced mobility, atrial fibrillation (irregular heartbeat at times), and major depressive disorder (causes feelings of lessened self- worth as well as feelings of sadness and loneliness). Observation on 04/25/2023 at 2:39 p.m. of the MA taking Resident #64's blood pressure, revealed the MA did not sanitize the blood pressure cuff before or after taking Resident #64's blood pressure. Observation on 04/25/2023 at 2:41 p.m. of MA taking Resident #57's blood pressure, revealed the MA did not sanitize the blood pressure cuff before or after taking Resident #57's blood pressure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676325 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Nursing and Rehabilitation Center 8707 Lakeside Parkway San Antonio, TX 78245 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/25/2023 at 2:44 p.m. of MA taking Resident #60's blood pressure, revealed MA did not sanitize the blood pressure cuff before or after taking Resident #60's blood pressure. During an interview with MA on 04/25/2023 at 2:50 p.m., MA stated she did not know that she should sanitize the blood pressure cuff before and after use with each resident. She further stated she was required to bring her own blood pressure cuffs to work from her home to utilized with the residents. When asked if she sanitized the blood pressure cuff utilized with Resident #57, Resident #60, or Resident #64 the MA stated she had never been taught in school or in the facility that she needed to sanitize the blood pressure cuff before or after use with each Resident, so she did not sanitize the blood pressure cuff before or after use with any of the resident's during the observations. During an interview with the ADON on 04/25/2023 at 3:31 p.m., the ADON stated the blood pressure cuff should be sanitized prior to and after use with each resident. She stated it was important to sanitize the equipment because it was unknown of what organism such as COVID-19, C. diff (clostridium difficile which was bacterium that can infect the bowel and cause diarrhea) ,or anything that could get on the cuff. The ADON went on to state, it might or might not have an effect on the resident, but it could because they could possibly get an infection, depending if anything got on the blood pressure cuff or not. During an interview with the DON on 04/25/2023 at 3:46 p.m. the DON stated, When taking blood pressures staff should make sure their equipment was clean by wiping it down, we provide specific wipes for equipment that all staff are trained to use. The DON further stated it was important to clean all equipment used with residents to prevent cross contamination. Policy provided by the facility on 4/26/2023 titled, Sanitation Services, Cleaning & Disinfection Resident Care Items & Equipment revealed the following: 1. Reusable resident items are cleaned and disinfected between residents. 2. Single use items are disposed of after a single use. 3. Durable medical equipment must be cleansed and disinfected before reuse by another resident. 4. Intermediate and low-level disinfectants will be utilized for non-critical items include: stethoscope, blood pressure machines etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676325 If continuation sheet Page 8 of 8